Hospitals across the United States are currently faced with converting paper-based medical records to electronic health records in an effort to improve the safety and quality of patient care. The American Recovery and Reinvestment Act of 2009 placed an impetus for the conversion by 2014 or else hospitals will face financial penalties from the Centers for Medicare and Medicaid Services. Nursing documentation is one component of an electronic health record. Nursing documentation was originally designed on paper to support nurses in their communication of patient-information needed for care across the health care team. Yet, little empirical evidence exists to describe how, why and for what purpose nurses use paper-based nursing documentation to collect and communicate patient-information needed for care in addition to other available verbal, written and electronic information sources. An understanding of the use of paper-based nursing documentation is necessary in order to effectively evaluate the use of electronic nursing documentation on the improvement of safety and quality of care to hospitalized patients. This dissertation will use a descriptive convergent mixed-methods multiple-case study design to investigate 2 cases. Each case will represent an inpatient pediatric unit within the Children's Hospital at Duke University Hospital in Durham, North Carolina who were using paper-based nursing documentation and converted to electronic nursing documentation on April 19, 2011. I will collect quantitative and qualitative data in 2 phases of data collection from multiple data sources. For each of the 2 cases I aim to 1) quantitatively and qualitatively describe nurses'collected and communicated patient information needs through verbal, written and electronic information sources from data obtained through observations, documents, field notes and interviews with nurses and health care team members on 1 medical and 1 surgical pediatric unit while using paper and subsequently electronic nursing documentation;2) integrate the quantitatively analyzed data with the qualitatively analyzed data in a joint matrix that will mix the data to describe collected and communicated patient information needs while using paper-based and subsequently electronically based nursing documentation;and 3) compare the joint matrices created in AIM 2 to describe similarities and differences within and between each unit while using paper based and subsequently electronically based nursing documentation. Findings from this study will be used to 1) create standards for nursing documentation in the provision of error-free care;2) enhance and refine the design of electronic nursing documentation systems to meet nurses'and health care team members'patient-information needs on inpatient units in hospital settings;and 3) identify hardware devices that integrate with nursing workflow to maximize the collection and communication of patient information needed for care of patient in hospital settings. PUBLIC HEALTH RELEVANCE: Hospitals across the U.S. are converting from paper to electronic nursing documentation in an effort to improve the safety and quality of patient care. The findings from this study will have implications for creating standards for nursing documentation and identifying areas for redesign of information technology to meet the needs of nurses and members of the health care team.